med surge 3

Which action would the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder? a. Teach the patient how to self-catheterize. b. Encourage decreased evening fluid intake. c. Suggest the use of adult incontinence briefs. d. Assist the patient to the commode every 2 hours

ANS A The patient may need to intermittently self-catheterize when urinary retention is not relieved by other means. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

. A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action would the nurse take first? a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan.

ANS B The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed

A patient who has nephrotic syndrome develops flank pain. Which treatment will the nurse plan to explain to this patient? a. Antifungals b. Antibacterials c. Anticoagulants d. Antihypertensives

ANS C Flank pain in a patient with nephrotic syndrome suggests a renal vein thrombosis and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Fungal pyelonephritis is uncommon and is treated with antifungals. Antihypertensives are used if the patient has high blood pressure

After ureterolithotomy, a patient has a urethral catheter and a left ureteral catheter in place. Which action will the nurse include in the plan of care? a. Apply continuous steady tension to the ureteral catheter. b. Provide teaching about how to remove and replace the catheters at home. c. Call the health care provider if the ureteral catheter output drops suddenly. d. Clamp the ureteral catheter off when output from the urethral catheter stops.

ANS C The health care provider should be notified urgently if the ureteral catheter output decreases because obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. The catheters are indwelling, and the patient will not be responsible for removing or replacing them.

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient reports having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

ANS b To prevent cerebral vasospasm and maintain cerebral perfusion, BP needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage Oral and IV agents may be used to maintain BP within a normal to high-normal range (SBP less than 160 mm Hg). An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure (BP) is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

ANS d The use of warfarin may have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated

Which patient would the nurse assess first after receiving change-of-shift report? a. A patient with esophageal varices who has a rapid heart rate b. A patient with a history of gastrointestinal bleeding who has melena c. A patient with nausea who has a dose of metoclopramide (Reglan) due d. A patient who is crying after receiving a diagnosis of esophageal cancer

ANS: A A patient with esophageal varices and a rapid heart rate indicate possible hemodynamic instability caused by GI bleeding. The other patients require interventions, but their findings do not indicate acutely life-threatening complications.

After change-of-shift report, which patient would the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as "like a band around my head" c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms

ANS: A Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse would assess this patient first. The other patients would be assessed but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.

Which action will the nurse include in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs). d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.

ANS: A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

A female patient who had a stroke 24 hours ago has expressive aphasia. Which intervention would the nurse use to help the patient communicate? a. Ask questions that the patient can answer with "yes" or "no." b. Develop a list of words that the patient can read and practice reciting. c. Have the patient practice her facial and tongue exercises with a mirror. d. Prevent embarrassing the patient by answering for her if she does not respond

ANS: A Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond

Which diagnostic test would the nurse anticipate for an older patient who is vomiting "coffee-ground" emesis? a. Endoscopy b. Angiography c. Barium studies d. Gastric analysis

ANS: A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding

A patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy would the nurse implement first? a. Insert urethral catheter. b. Obtain renal ultrasound. c. Draw a complete blood count. d. Infuse normal saline at 50 mL/hr.

ANS: A The patient's elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of an indwelling catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions are appropriate but would be implemented after the catheter.

A 76-yr-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider would the nurse implement first? a. Insert an indwelling urinary catheter. b. Draw blood for a serum creatinine level. c. Schedule an intravenous pyelogram (IVP). d. Administer lorazepam (Ativan) 0.5 mg PO

ANS: A The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve after the bladder distention is corrected, and sedative drugs would be used cautiously in older patients. The IVP may be done as a diagnostic test but does not need to be done urgently

After receiving change-of-shift report on the following four patients, which patient would the nurse see first? a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled d. A 40-yr-old patient who had a transient ischemic attack yesterday and has a dose of aspirin due

ANS: A tPA needs to be infused within the first few hours after stroke symptoms start to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

An adult patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect? a. Poor skin turgor b. Recent weight gain c. Elevated urine ketones d. Decreased blood pressure

ANS: B The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. Ketones are not related to nephrotic syndrome.

. Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful? a. Split-pea soup, English muffin, and nonfat milk b. Poached eggs, whole-wheat toast, and apple juice c. Oatmeal with cream, half a banana, and herbal tea d. Cheese sandwich, tomato soup, and cranberry juicev

ANS: B Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in sodium and phosphate, and tomato soup is high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and cream is high in phosphate.

Which assessment finding would the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30? a. Persistent skin tenting b. Rapid, deep respirations c. Hot, flushed face and neck d. Bounding peripheral pulses

ANS: B Patients with metabolic acidosis caused by AKI may have Kussmaul respirations to eliminate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI.

A patient has arrived for a scheduled hemodialysis session. Which nursing action is appropriate for the registered nurse (RN) to delegate to a dialysis technician? a. Teach the patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for causes of an increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis.

ANS: B Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.

The nurse is planning care for a patient with severe heart failure who has developed increased blood urea nitrogen (BUN) and creatinine levels. Which aim will be the primary treatment goal? a. Augmenting fluid volume b. Maintaining cardiac output c. Diluting nephrotoxic substances d. Preventing systemic hypertension

ANS: B The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. Renal failure caused by hypertension, hypovolemia, or nephrotoxins would be managed by interventions specific to those problems.

Which topic would the nurse include when teaching the patient ways to prevent the recurrence of kidney stones? a. Using a filter to strain all urine b. Drinking 3000 mL of fluid each day c. Avoiding dietary sources of calcium d. Choosing diuretic fluids such as coffee

ANS: B A fluid intake of 2000 to 3000 mL/day is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with kidney stones. Coffee tends to increase stone recurrence. Straining all urine routinely after a stone has passed will not prevent stones.

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 bloody stools a day. Which intervention would the nurse include in the patient's plan of care? a. Administer oral metoclopramide. b. Instruct the patient not to eat or drink. c. Administer cobalamin (vitamin B12) injections. d. Teach the patient about total colectomy surgery.

ANS: B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate during this acute phase.

Which nursing action will the nurse include in the plan of care for a patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict IV fluid intake. b. Monitor stools for blood. c. Ambulate six times daily. d. Increase dietary fiber intake.

ANS: B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Dietary fiber may increase gastrointestinal motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

A 48-yr-old male patient who weighs 242 lb (110 kg) undergoes a left nephrectomy for massive kidney trauma from a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon? a. Blood pressure is 102/58. b. Urine output is 20 mL/hr for 2 hours. c. Incisional pain level reported as 9/10. d. Crackles present at bilateral lung bases.

ANS: B Because the urine output should be at least 0.5 mL/kg/hr, a 40-mL output for 2 hours indicates that the patient may have decreased perfusion to the remaining kidney because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain

Which information will the nurse monitor to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

ANS: B Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate

Which item would the nurse offer to the patient restarting oral intake after being NPO due to nausea and vomiting? a. Glass of orange juice b. Dish of lemon gelatin c. Cup of coffee with cream d. Bowl of hot chicken broth

ANS: B Clear cool liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.

Which information about clopidogrel (Plavix) will the nurse provide to the patient who has cerebral atherosclerosis? a. Monitor and record the blood pressure daily. b. Call the health care provider if stools are tarry. c. Clopidogrel will dissolve clots in the cerebral arteries. d. Clopidogrel will reduce cerebral artery plaque formation

ANS: B Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients would be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.

female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information would the nurse report promptly to the health care provider? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient's abdomen appears bloated after the inflow. d. The patient has abdominal pain during the inflow phase.

ANS: B Cloudy-appearing peritoneal effluent is a sign of possible peritonitis and would be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.

Several weeks after a stroke, a patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which intervention would the nurse plan to begin an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Use an external catheter to protect the skin and prevent embarrassment. d. Perform intermittent catheterization after each voiding to check for residual urine.

ANS: B Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200-mL fluid restriction may lead to dehydration. Intermittent catheterization and use of an external catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection and skin breakdown.

Which information will the nurse provide for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may reduce your symptoms." b. "Keep the head of your bed elevated on blocks." c. "Avoid eating between meals to reduce acid secretion." d. "Vigorous exercise may increase the incidence of reflux."

ANS: B Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

A patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider? a. Urinary urgency b. Left-sided flank pain c. Intermittent hematuria d. Burning with urination

ANS: B Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection.

A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates a need for additional teaching about GERD? a. "I quit smoking years ago, but I chew gum." b. "I eat small meals and have a bedtime snack." c. "I take antacids between meals and at bedtime each night." d. "I sleep with the head of the bed elevated on 4-inch blocks."

ANS: B GERD is exacerbated by eating late at night, and the nurse would plan to teach the patient to avoid eating within 3 hours of bedtime. Smoking cessation, taking antacids, and elevating the head of the bed are appropriate actions to control symptoms of GERD.

Which laboratory result would the nurse check before administering calcium carbonate to a patient with chronic kidney disease? a. Serum potassium b. Serum phosphate

ANS: B If serum phosphate is increased, the calcium and phosphate can cause soft tissue calcification. When calcium levels are increased or there is evidence of existing vascular or soft tissue calcifications, non-calcium-based phosphate binders are used. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered.

Which statement by the nurse is most likely to help a 22-yr-old patient with extreme obesity in losing weight on a 1000-calorie diet? a. "It will be necessary to change lifestyle habits permanently to maintain weight loss." b. "You are likely to notice changes in how you feel after a few weeks of diet and exercise." c. "You will decrease your risk for future health problems such as diabetes by losing weight now." d. "Most of the weight that you lose during the first weeks of dieting is water weight rather than fat."

ANS: B Motivation is a key factor in successful weight loss and a short-term outcome provides a higher motivation. Future health problems are unlikely to motivate a 22-yr-old patient. Telling a patient that the initial weight loss is water would be discouraging, although this may be correct. Changing lifestyle habits permanently is recommended, but this process occurs over time, and discussing this is not likely to motivate the patient.

Which recommendation would the nurse provide to a patient with myasthenia gravis (MG)? a. Anticipate the need for weekly plasmapheresis treatments. b. Complete physically demanding activities early in the day. c. Protect the extremities from injury due to poor sensory perception. d. Perform frequent weight-bearing exercise to prevent muscle atrophy

ANS: B Muscles are generally strongest in the morning, and muscle weakness is prominent by the end of the day, so activities involving muscle activity should be scheduled early. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG. Muscle atrophy does not occur because although muscles are weak, they are still used.

After change-of-shift report, which patient would the nurse assess first? a. Patient who has cloudy urine after bladder reconstruction b. Patient with a urethral stricture who has not voided for 12 hours c. Patient who voided bright red urine after returning from lithotripsy d. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg

ANS: B Not voiding for 12 hours suggests acute urinary retention, which is a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or intervention.

A patient has had recurrent uric acid kidney stones. Which diet items would the nurse recommend that the patient avoid or limit? a. Milk and cheese b. Sardines and liver c. Spinach and chocolate d. Legumes and dried fruit

ANS: B Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

A patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8-hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. d. The glomerular filtration rate is less than 30 mL/min/1.73 m2 .

ANS: B The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.

A 74-yr-old patient who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I would go on dialysis?" Which initial response would the nurse provide? a. "It depends on which type of dialysis you are considering." b. "Tell me more about what you are thinking regarding dialysis." c. "You are the only one who can make the decision about dialysis." d. "Many people your age use dialysis and have a good quality of life."

ANS: B The nurse would initially clarify the patient's concerns and questions about dialysis. The patient is the one responsible for the decision, and many people using dialysis do have good quality of life, but these responses block further assessment of the patient's concerns. Referring to which type of dialysis the patient might use only indirectly responds to the patient's question

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient's Glasgow Coma Scale score? a. 9 b. 11 c. 13 d. 15

ANS: B The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

. The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? a. The bowel sounds are hyperactive in all four quadrants. b. The patient's lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patient's blood pressure (BP) has increased to 142/84 mm Hg

ANS: B The patient's lung sounds indicate that pulmonary edema may be developing because of the rapid infusion of IV fluid and that the fluid infusion rate would be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding.

A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action would the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid. d. Elevate the foot of the bed.

ANS: B The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe.

. After the nurse teaches about the recommended amounts of foods from animal and plant sources, which menu selections indicate that the patient understands the diet instructions? a. 3 oz of lean beef, 2 oz of low-fat cheese, and a sliced tomato b. 3 oz of roasted pork, a cup of broccoli, and a cup of carrot sticks c. Cup of tossed salad and nonfat dressing topped with a chicken breast d. Half cup of tuna mixed with nonfat mayonnaise and a half cup of celery

ANS: B This selection is most consistent with the recommendations to limit foods from animal sources and increase plant source foods. The other choices all have higher ratios of animal origin foods to plant source foods than would be recommended.

A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. More protein is allowed because urea and creatinine are removed by dialysis. c. Dietary potassium is not restricted because the level is normalized by dialysis. d. Unlimited fluids are allowed because retained fluid is removed during dialysis.

ANS: B When the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Glucose is not lost during hemodialysis. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes.

A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, which action would the nurse take? a. Order a varied pureed diet. b. Assess the patient's appetite. c. Assist the patient into a chair. d. Offer the patient a sip of juice.

ANS: C The patient should be as upright as possible before attempting to feed to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted

A patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? a. The patient has been vomiting for 4 days. b. The patient takes antacids 8 to 10 times a day. c. The patient is lethargic and difficult to arouse. d. The patient had a small intestinal resection 2 years ago.

ANS: C A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information is also important to collect, but it does not require as quick action as the risk for aspiration.

After change-of-shift report, which patient would the nurse assess first? a. A 42-yr-old patient who has acute gastritis and ongoing epigastric pain b. A 70-yr-old patient with a hiatal hernia who experiences frequent heartburn c. A 60-yr-old patient with nausea and vomiting who is lethargic with dry mucosa d. A 53-yr-old patient who has dumping syndrome after a recent partial gastrectomy

ANS: C A patient with nausea and vomiting who is lethargic with dry mucosa is at high risk for problems such as aspiration, dehydration, and fluid and electrolyte disturbances. The other patients will also need to be assessed, but the information about them indicates symptoms that are typical for their diagnoses and are not life threatening.

After change-of-shift report, which patient would the nurse assess first? a. A 42-yr-old patient who has acute gastritis and ongoing epigastric pain b. A 70-yr-old patient with a hiatal hernia who experiences frequent heartburn c. A 60-yr-old patient with nausea and vomiting who is lethargic with dry mucosa d. A 53-yr-old patient who has dumping syndrome after a recent partial gastrectomy

ANS: C A patient with nausea and vomiting who is lethargic with dry mucosa is at high risk for problems such as aspiration, dehydration, and fluid and electrolyte disturbances. The other patients will also need to be assessed, but the information about them indicates symptoms that are typical for their diagnoses and are not life threatening.

A patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), which assessment would the nurse plan to make more frequently than is routine? a. Apical pulse b. Bowel sounds c. Breath sounds d. Abdominal girth

ANS: C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider would the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Begin tissue plasminogen activator (tPA) intravenously per protocol

ANS: C Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is greater than 130 mm Hg or systolic pressure is greater than 220 mm Hg. Fluid intake should be 1500 to 2000 mL/day to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

Which assessment would the nurse identify as most important regarding a patient who has myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

ANS: C Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action would the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

ANS: C Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention would the nurse include in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c . Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

ANS: C Because the patient has difficulty feeding himself, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition

Which prescribed action will the nurse implement first for a patient who has vomited 1100 mL of blood? a. Give an IV H2 receptor antagonist. b. Draw blood for type and crossmatch. c. Administer 1 L of lactated Ringer's solution. d. Insert a nasogastric (NG) tube and connect to suction

ANS: C Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities.

Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Cherry gelatin with fruit d. Peanut butter and jelly sandwich

ANS: C Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure

A patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information would the nurse discuss with the health care provider before giving the medication? a. Creatinine 1.6 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg

ANS: C High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) so the recommendation is to use the lowest possible dose of erythropoietin. Hemoglobin levels well in the normal range indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered.

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b . The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

ANS: C Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase their risk for stroke. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication being taken by the patient indicates a need for patient teaching? a. Acetaminophen b. Calcium phosphate c. Magnesium hydroxide d. Multivitamin with iron

ANS: C Magnesium is excreted by the kidneys, so patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD.

A licensed practical/vocational nurse (LPN/VN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention? a. The LPN/VN assists the patient to ambulate in the hallway. b. The LPN/VN administers the erythropoietin subcutaneously. c. The LPN/VN administers the iron supplement and phosphate binder with lunch. d. The LPN/VN carries a tray containing low-protein foods into the patient's room.

ANS: C Oral phosphate binders would not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder would be given with a meal and the iron given at a different time. The other actions by the LPN/VN are appropriate for a patient with renal insufficiency.

. Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient leaves the catheter exit site without a dressing. b. The patient plans 30 to 60 minutes for a dialysate exchange. c. The patient cleans the catheter while in the bathtub each day. d. The patient slows the inflow rate when experiencing abdominal pain

ANS: C Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis.

Which concern would the nurse anticipate for a patient who had a right hemisphere stroke? a. Right-sided hemiplegia b. Speech-language deficits c. Denial of deficits and impulsiveness d. Depression and distress about disability

ANS: C The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action would the nurse take? a. Assist the patient to cough and deep breathe. b. Palpate the abdomen for rebound tenderness. c. Suggest the patient lie on the side, flexing the right leg. d. Encourage the patient to sip clear, noncarbonated liquids

ANS: C The patient's clinical manifestations are consistent with appendicitis. Lying still with the right leg flexed is often the most comfortable position. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is the priority? a. Encourage the patient to drink more fluids. b. Plan to monitor the patient's intake and output. c. Use an ultrasound scanner to check the postvoiding residual volume. d. Reassure the patient that urinary problems are common after rectal surgery.

ANS: C The patient's history and clinical manifestations are consistent with overflow incontinence, so an ultrasound scanner can be used to check for residual urine after the patient voids. The other interventions may also be useful, but the priority patient problem is the potentially overfilled bladder

Which topic would the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, and dysarthria with no residual effects? a. Cerebral aneurysm clipping b. Heparin intravenous infusion c. Oral low-dose aspirin therapy d. Tissue plasminogen activator (tPA)

ANS: C The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

Which prescribed intervention would the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Administer lorazepam (Ativan) 4 mg IV. d. Obtain computed tomography (CT) scan.

ANS: C To prevent ongoing seizures, the nurse would administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but cannot be done while the patient is seizing. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse would assess LOC after the seizure.

A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. What would the nurse ask the patient about to determine possible risk factors for gastritis? a. The amount of saturated fat in the diet b. A family history of gastric or colon cancer c. Use of nonsteroidal antiinflammatory drugs d. A history of a large recent weight gain or loss

ANS: C Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.

The health record indicates that a patient has an occluded left posterior cerebral artery. Which finding would the nurse anticipate? a. Dysphasia b. Confusion c. Visual deficits d. Poor judgment

ANS: C Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.

A patient is being admitted with a possible stroke. Which information from the nursing assessment indicates that the patient is more likely to be having a hemorrhagic stroke than a thromboembolic stroke? a. The patient has intermittent bouts of atrial fibrillation. b. The patient has had brief episodes of right-sided hemiplegia. c. The patient has a history of treatment for infective endocarditis. d. The patient reports that the symptoms began with a severe headache.

ANS: D A sudden onset headache is typical of a subarachnoid hemorrhage. Atrial fibrillation and infective endocarditis are a risk factors for thrombotic or embolic stroke. Brief episodes of right-sided hemiplegia are consistent with transient ischemic attack and risk for embolic stroke.

. Which topic would the nurse anticipate teaching to a patient who has a new report of heartburn? a. Radionuclide tests b. Barium swallow exam c. Endoscopy procedures d. Proton pump inhibitors

ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

. Which finding by the nurse will be most helpful in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)? a. Bladder distention b. Foul-smelling urine c. Suprapubic discomfort d. Costovertebral tenderness

ANS: D Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of a lower UTI and are likely to be present if the patient also has an upper UTI

A patient reports leg cramps during hemodialysis. Which action would the nurse take? a. Massage the patient's legs. b. Reposition the patient supine. c. Give acetaminophen (Tylenol). d. Infuse a bolus of normal saline

ANS: D Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.

After sleeve gastrectomy, a 42-yr-old male patient returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control. Which nursing action would be included in the postoperative plan of care? a. Offer sips of fruit juices at frequent intervals. b. Irrigate the nasogastric (NG) tube frequently. c. Remind the patient that PCA use may slow the return of bowel function. d. Support the surgical incision during patient coughing and turning in bed.

ANS: D Protecting the incision from strain decreases the risk for wound dehiscence. The patient should be encouraged to use the PCA because pain control will improve the cough effort and patient mobility. NG irrigation may damage the suture line or overfill the stomach pouch. Sugar-free clear liquids are offered during the immediate postoperative time to decrease the risk for dumping syndrome.

A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which other finding would the nurse expect? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

ANS: D Right-sided paralysis indicates a left-brain stroke, which is also associated with difficulty in comprehension and use of language: the left hemisphere is dominant for language skills in right-handed persons and in most left-handed persons. Impulsive behavior and neglect are more likely with a right-side stroke. The left-side reflexes are likely to be intact.

Which assessment would the nurse perform first for a patient who just vomited bright red blood? a. Measuring the quantity of emesis b. Palpating the abdomen for distention c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

ANS: D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal bleeding. BP and pulse are the best indicators of these complications. The other information is important to obtain, but BP and pulse rate are the best indicators for assessing intravascular volume

After receiving change-of-shift report, which patient would the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L d. Patient who has just returned from having hemodialysis with a heart rate of 110/min

ANS: D The patient who has tachycardia after hemodialysis may be bleeding or excessively hypovolemic and would be assessed immediately for these complications. The other patients also need assessments or interventions but are not at risk for life-threatening complications.

patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). Which interprofessional intervention at would the nurse anticipate for this patient? a. Surgical endarterectomy b. Transluminal angioplasty c. Intravenous heparin drip administration d. Tissue plasminogen activator (tPa) infusion

ANS: D The patient's history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.